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F R OFFICE USE.. �` ---------------`� , /x/63 Zx -� G APPLICATION FOR SANITATION PERMIT Permit No_ _________________•..__.. __ _ Sl______________ (Complete to Duplicate) Date Issued ��`,`l�,t�__ --------------------------------------._.____-------- This Permit Expires 1 Year From Date Issued Application is hereby made to the,San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549_ JOB ADDRESS AND LO TIO/N-_--=----- - ��----------- ......... r,/ -------------------------------------------- ---------------- Owner's Name-------------- C // _ --s' ;,r Phone. ' Address-------_--- __ 'R k . �C - Phone----------------Contractor`s Name------------------------- G2 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ _._ Nu r of bedrooms5:� �Number of baths/_-_ Lot size -___--Xe" ------------------------ Water Supply: Public system Community system El private [] Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (if yes,date_.- -------------- No lew Construction: Yes ®/No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 204 feet.) Septic Tan Distance from nearest well------.--- ------Distance from foundation_/�__--._�Material-__�_ . ..... _-.. QLiquid depth_'7-/�-_�-__-_----Capacityr� �.___-- No, of compartments___-_- _-____5ize-- �-- -- / 1 Disposal d: Distance from nearest well------------------_Distance from foundation__��J-----__.Distance to nearest lot Eine__ Number of lines__ti__`__,-- -_- ........I____---Length of each line-------- -� Width of trench /J Type of filter material__/_ - �� pth of filter material_ ._ %___Total length___ __. �__ __________________-_ Seepage Distance to nearest well___ -_-____Distance from foundation___,._10-__--_.Distance to nearest lot line______-_ Number of pits---_____-_- _ __Lining material�[�a .? _.Size: Diameter-- _.'�-__.--_Depth_ - 1-tca-___ Cesspool: Distance from, nearest well------_-_-.-____Distance from foundation-----___-----------_Lining material....___-.-_---.____.__.-_________-__. �/► ❑ Size: Diameter---------------------------- -- - Depth--------------------------------------Y------------Liquid Capacity----------------------------gaIs. ' Privy:: Distance from nearest well-------------------------------------------------Distance from nearest building_ ---_-__-_________________-__---_____. ❑ Distance to nearest lot line -------------------------- ----------------------------------------- --------------------------- ! Remodeling and/or repairing (describe):----------- = e� `- -------------------------------- -----------•-----------------••-•-----•----------•-------]------------------------ --------------------------------------------------------------------------- ------------------------------------- --------- ...... ----------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------:-------- ------------- -- 1 ---------------------------------------------------------- -----------------------------------------I------------------------- I ----------••--------------------------•------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin.Local Healfh-Distriet. (Signed)--------------------- -- - ----- (Owner and/or Contractor) 1 ----------------------------------{Title] r�� p„--— -- -------------- By:---------------------------- - ------------- � y i (Plot plan, showing size d( t, location of system to relation to wells, buildings, etc`, can be placed on oreverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---t v--- - -- ---------------------------- ---------------------------------------- DATE--- - --- ----------------------------- REVIEWEDBY-------- ----------------------E------------- ---------------------------- ------------------------------------ --------- DATE-------- --------- ------------------------------------ BUILDING PERMIT ISSUED------------------------ SSUED------------------------ -------- ------------ ----------------------------- --------- DATE--- ------------------------------- -------------- Alterations and/or recommendations---____-�/A'��. ------ - � �------- �= ----------------------------------------------- -tL", _P- y-; F� >J 4/s ------- -- - --- --------------- --------- .-- ----- ----- -- - -- - (!. Z inn- -----------------— 1 ��1 z _ - - _ � �----------- ------------------------------------------ ----------- -------- -------------------•----- --------------------• ------------------------------------------------------- I - ------ ------------------------------ -------- -------------------- FINAL ------------------ FINAL INSPECTION BY:.----� -------------- ------- -------- Date.---- ----------- -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hasellan Ave. 300 West Oak street i" 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C C.